Download FLUORESCEIN CLEARANCE TEST (TEAR DYNAMIC

FLUORESCEIN CLEARANCE TEST
(TEAR DYNAMIC FUNCTIONAL TEST)
1. Ocular Surface Center Code: T 3001
2. Introduction:
The ocular surface is covered by a thin layer of preocular tear film, of which the
aqueous fluid is secreted by the lacrimal gland, spread over the entire ocular surface
by lid blinking, and then cleared from the eye into the nose through the nasolacrimal
drainage system. Therefore, a complete knowledge of all hydrodynamic elements,
i.e., tear secretion (flow), tear volume, and tear clearance or turnover, is important
for complete evaluation of tear dynamic function..
Clinically, measurement of tear secretion relies on the Schirmer test. However,
one common way of measuring tear clearance is to judge the speed of disappearance
from the ocular surface of exogenously added fluorescein, a method originally use by
Nover and Jaeger 1. Various methods have been developed and can be grossly
subdivided into two major groups. The first group detects how fast the dye appears in
the nasal cavity. This is accomplished by the use of a Q tip in the traditional Jones I
test 2, or by direct visualization through endoscopy 3. The second group measures
how slow the dye is still retained on the ocular surface. This can be achieved by
visual semiquantitation 4,5, wetting with Schirmer strips 1, or fluorophotometry 6, of
which the latter can be directed to the marginal strip 6,7 or to the precorneal tear film 811
.
3. Method of Operation:
As reported 12-15, the fluorescein clearance test (FCT) is performed as follows.
After applying one drop of 0.5 % proparacaine (Alcon Laboratories, Inc., Humacao,
PR) to each eye, the inferior fornix was carefully dried with tissue paper. An aliquot
of 5 µl of FluoressR (Akorn Inc., Abita Springs, LA) containing 0.25 % fluorescein
and 0.4 % benoxinate hydrochloride was then applied to the inferior fornix of each
eye through an Eppendorf pipette (Rainin Instrument Co., Woburn, MA) without
directly touching the conjunctival surface. The patient continued to sit in the
examination room under the ambient light and was asked to blink normally. After a
lapse of 10 min, determined by a timer, a Schirmer paper strip (Alcon Laboratories,
Inc., Fort Worth, TX) was inserted into the inferior fornix of each eye at a position
approximately one third lateral to the temporal caruncle. After one min, during which
time the eye is closed. This maneuver was repeated for a total of 3 times over a
period of 30 min, i.e., every 10 min. At the end of the 30 min, i.e., the last test,
Schirmer strip was inserted after nasal stimulation with a Q-tip.
4. Interpretation:
The FCT allows one to determine the following three important tear dynamic
functions, i.e., basal tear secretion, reflex tear secretion under nasal stimulation, and
tear clearance, at the same time.
Normal
Wetting length: all > 3 mm
Increased wetting length in the end
Dye disappears by 15 min
Unilateral DTC
ATD with Reflex
< 3 mm when anesthetized
Increased wetting length in the end
Dye disappears by 15 min
ATD with Reflex
Wetting length: < 3 mm only in the beginning
Dye clears before 15 min
ATD without Reflex
< 3 mm throughout
Delayed dye clearance
Bilateral DTC
[Note]: Normal: Normal tear secretion and
normal tear clearance.
ATD: Aqueous tear deficiency
Reflex: With reflex tearing
DTC: Delayed tear clearance
Wetting length: > 3mm throughout
> 3 mm throughout
Dye never clears, but dilutes with time Dye never clears, and nearly not diluted
(Partial Block)
(Complete Block)
5. Clinical Uses:
1) To determine aqueous tear deficiency (dry eye) with higher accuracy 15,16
2) To differentiate dry eye into with or without reflex tearing. Sjogren syndrome
or primary lacrimal gland diseases are characterized by the loss of reflex
tearing 17, thus helping establish the severity of dry eye
3) To guide physicians to perform punctal occlusion with plugs or permanent
cauterization
4) To determine if punctal occlusion is performed with efficacy
5) To determine subclinical DTC as a cause of ocular irritation, medicamentosa
and other ocular surface disorders 14,18-20, and help direct more effective
treatments such as non-preserved methylprednisolone 14,21
6. Literature:
1. Nover A, Jaeger W. Kolorimetrische Methode zur Messung der Tranensekretion (FluoreszeinVerdunnungstest). Klin Mbl Augenheilk. 1952;121:419-425.
2. Jones LT. The lacrimal secretory system and its treatment. Am J Ophthalmol. 1966;62:47-60.
3. Tucker NA, Codere F. The effect of fluorescein volume on lacrimal outflow transit time. Ophthal
Plast & Reconstr Surg. 1994;10:256-259.
4. Norn MS. Tear secretion in normal eyes. Estimated by a new method: the lacrimal streak dilution
test. Acta Ophthalmol (Copenh). 1965;43:567-573.
5. Zappia RJ, Milder B. Lacrimal drainage function. 2. The fluorescein dye dispearance test. Am J
Ophthalmol. 1972;74:160-162.
6. Mishima S, Gasset A, Klyce SDJr, Baum JL. Determination of tear volume and tear flow. Invest
Ophthalmol. 1966;5:264-276.
7. Jordan A, Baum J. Basic tear flow. Does it exist? Ophthalmology. 1980;87:920-930.
8. Puffer MJ, Neault RW, Brubaker RF. Basal precorneal tear turnover in the human eye. Am J
Ophthalmol. 1980;89:369-376.
9. Webber WRS, Jones DP, Wright P. Fluorophotometric measurements of tear turnover rate in normal
healthy persons: evidence for a circadian rhythm. Eye. 1987;1:615-620.
10. Occhipinti JR, Mosier MA, LaMotte J, Monji GT. Fluorophotometric measurement of human tear
turnover rate. Curr Eye Res. 1988;7:995-1000.
11. van Best JA, Benitez del Castillo JM, Coulangeon L-M. Measurement of basal tear turnover using a
standarized protocol. European concerted action on ocular fluorometry. Graefe's Arch Clin Exp
Ophthalmol. 1995;233:1-7.
12. Linden C, Alm A. The effect of reduced tear drainage on corneal and aqueous concentrations of
topically applied fluorescein. Acta Ophthalmol (Copenh). 1990;68 :633-638.
13. Pflugfelder SC, Tseng SCG, Pepose JS, Fletcher MA, Klimas N, Feuer W. Epstein-Barr virus
infection and immunological dysfunction in patients with aqueous tear deficiency. Ophthalmology.
1990;97:313-323.
14. Prabhasawat P, Tseng SCG. Frequent association of delayed tear clearance in ocular irritation. Br J
Ophthalmol. 1998;182:666-675.
15. Xu K-P, Yagi Y, Toda I, Tsubota K. Tear function index. A new measure of dry eye. Arch
Ophthalmol. 1995;113:84-88.
16. Pflugfelder SC, Tseng SCG, Sanabria O, Kell H, Garcia CG, Felix C, Feuer W, Reis BL.
Evaluation of subjective assessments and objective diagnostic tests for diagnosing tear-film
disorders known to cause ocular irritation. Cornea. 1998;17:38-56.
17. Anderson DF, Prabhasawat P, Alfonso E, Tseng SCG. Amniotic membrane transplantation after the
primary surgical management of band keratopathy. Cornea. 2001;20:354-361.
18. Barton K, Monroy D, Nava A, Pflugfelder SC. Inflammatory cytokines in tears of patients with
ocular rosacea. Ophthalmology. 1997;104:1868-1874.
19. Afonso AA, Sobrin L, Monroy DC, Selzer M, Lokeshwar B, Pflugfelder SC. Tear fluid gelatinase B
activity correlates with IL-1α concentration and fluorescein clearance in ocular rosacea. Invest
Ophthalmol Vis Sci. 1999;40:2506-2512.
20. Afonso AA, Monroy D, Stern ME, Tseng SCG, Tseng SCG, Pflugfelder SC. Correlation of tear
fluorescein clearance and Schirmer test scores with ocular irritation symptoms. Ophthalmology.
1999;106:803-810.
21. Marsh P, Pflugfelder SC. Topical nonpreserved methylprednisolone therapy for keratoconjunctivitis
sicca in Sjogren syndrome. Ophthalmology. 1999;106:811-816.